- Email: [email protected]
Simulation Experience Enhances Medical Students' Interest in Cardiothoracic Surgery
Leora J. Tesche, MD, Richard H. Feins, MD, Matthew M. Dedmon, PhD, Kimberly N. Newton, MPH, Thomas M. Egan, MD, MS, Benjamin E. Haithcock, MD, Nirmal K. Veeramachaneni, MD, and Michael E. Bowdish, MD Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Background. Applications to cardiothoracic training programs have declined dramatically. Increased effort in recruiting trainees is paramount. In this study, we test our hypothesis that mentored instruction on cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery. Methods. First- and second-year medical students were recruited from a “surgery interest group” to receive mentored instruction on high-fidelity cardiothoracic simulators. Before and after simulation assessment tools were used to assess attitudes toward simulation, general surgery, and cardiothoracic surgery. Results. Forty-four medical students participated in the study. Although 80% of the students were interested in pursuing a career in surgery before the course, the majority (64%) indicated they were “neutral” about pursuing a career in cardiothoracic surgery. After participating in the course, 61% of the students agreed or strongly agreed that they were interested in pursuing a career in
cardiothoracic surgery (p ⴝ 0.001). When asked to select a surgical subspecialty for their third-year clerkship rotation, 18% of the students selected thoracic surgery before participating in the simulator course versus 39% after completing the course. This increase was most evident among the female participants, of whom only 3 (12%) selected a thoracic rotation before the simulator course versus 9 (35%) after completion of the course (p < 0.05). Conclusions. High-fidelity surgical simulators are an effective way to introduce medical students to cardiothoracic surgery. Participation in moderated simulator sessions improves attitudes toward cardiothoracic surgery as a career choice and correlates with a greater interest in selecting thoracic surgery as a third-year clerkship rotation. The role of surgical simulation as a recruitment tool should be further delineated.
I
potential recruits to gain exposure to the field of cardiothoracic surgery. First, duty hour restrictions have resulted in decreased time spent on subspecialty service rotations during general surgery training [5]. General surgery residents now have limited access to mentors within the field of cardiothoracic surgery. Second, the technically challenging nature of cardiothoracic procedures and tight margin for error make it difficult for junior residents to gain hands-on exposure in the operating room. Limited exposure to cardiothoracic surgery hinders recruitment as residents are asked to make career choices about field in which they have insufficient experience. As more integrated training tracts become available, the lack of exposure to cardiothoracic surgery will affect not only the general surgery applicant but medical students as well. To attract more trainees into the field of cardiothoracic surgery, new methods of recruitment are being explored. In this study, we describe the use of a surgical simulation course as a means to provide junior medical students exposure to cardiothoracic surgery. Surgical simulation is currently utilized to augment the education of residents in many different fields of surgery. Through structured courses, residents can be taught new procedures and surgical competency can be assessed [11, 12]. At the
n the past decade, the field of cardiothoracic surgery has witnessed a progressive decline in the number of applicants [1, 2]. Only 68% of accredited cardiothoracic programs matched residents in 2009 [3]. At the same time, more than 50% of those in the cardiothoracic workforce are over the age of 55 and expected to retire within the next 10 years [4, 5]. This disparity is projected to result in an 18% overall decrease in practicing cardiothoracic surgeons by 2010 [5]. As the “baby boom” population continues to age, the demand for qualified cardiothoracic surgeons is expected to increase [5]. To ensure sustainability of the profession and appropriate supply of qualified surgeons, increased efforts in the recruitment of trainees in cardiothoracic surgery is paramount. Studies demonstrate that, among junior residents, surgical career selection is most influenced by hands-on participation and positive mentorship within a field [3, 6 –10]. Several factors make it particularly difficult for
Accepted for publication June 29, 2010. Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010. Address correspondence to Dr Tesche, Department of Surgery, CB#7050, 4001 Burnett-Womack Bldg, Chapel Hill, NC 27599; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2010;90:1967–74) © 2010 by The Society of Thoracic Surgeons
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.06.117
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Simulation Experience Enhances Medical Students’ Interest in Cardiothoracic Surgery
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University of North Carolina at Chapel Hill, we have experience in the design of high-fidelity cardiac and pulmonary simulators that have been utilized in the instruction of cardiothoracic residents at national training courses [13, 14]. These simulators allow participants to perform complex cardiothoracic procedures in a realistic, yet protected, environment. Thus far, the simulators have been utilized for senior level instruction. However, we propose that the application of these simulators be extended to include instruction of medical students as well. In this study, we test our hypothesis that mentored instruction by cardiothoracic attendings on high-fidelity cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery.
Material and Methods The Surgery Interest Group at the University of North Carolina at Chapel Hill is an organization open to all first- and second-year medical students who express interest in surgery. Approximately 15% of the 320 firstand second-year students choose to participate each year. These members were offered the opportunity to participate in the cardiothoracic simulation course. During this half-day course, students received mentored instruction by cardiothoracic attendings on four highfidelity simulators: virtual bronchoscopy, thoracotomy, thoracoscopy, and beating heart models. (The thoracotomy and thoracoscopy simulators were designed and created by medical students and residents at UNC– Chapel Hill.) Students were paired in groups of two and given 30 minutes to perform mentored procedures on each model. Participants in the course wore surgical attire, and all models were properly draped to replicate the operating room experience. Before the course, the students were given a brief introduction to relevant anatomy as well as instruction on basic instrument handling. This study was reviewed and approved by the University of North Carolina Medical Institutional Review Board.
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is encountered during single lung ventilation. For this station, the participants were oriented to the anatomy of the lung and performed portions of a lobectomy including vessel isolation and ligation and removal of various anatomic segments of the lung. The students were also introduced to surgical stapling techniques.
Thoracoscopic Simulator The thoracoscopic simulator utilizes porcine right lungs injected with silicone in random positions on the lung surface to represent tumors. The lungs are positioned within a life-sized artificial hemithorax. Two openings in the hemithorax accommodate 12-mm ports for the thoracoscope and thoracoscopic instruments. A third opening in the fourth interspace of the midaxillary line is used for additional thoracoscopic instrumentation as well as tissue removal. In this station, participants were introduced to thoracoscopic surgery and techniques. The students were given the tasks of identifying pulmonary lesions and performing thoracoscopic wedge resection of these lesions.
Cardiac Simulator The cardiac simulator is a high-fidelity instrument that utilizes porcine hearts [15]. The hearts have been prepared so that, when connected to a computerized pneumatic pump, they are able to simulate cardiac movement. The coronary vessels and aortic root are fully perfused with synthetic blood. For this station students were oriented to cardiac anatomy, instructed on the fundamentals of cardiopulmonary bypass and placed aortic and venous cannulas.
Assessment Tools
The bronchoscopy simulator (AccuTouch; Immersion Medical, San Jose, CA) uses computer simulation to provide virtual images of endobronchial anatomy while the student manipulates a bronchoscope. The software on this model enables trainees to rehearse different clinical scenarios. For this task, the medical students completed a diagnostic bronchoscopy. This station emphasized techniques of bronchoscope manipulation, anatomy of the airway, and identification of lesions within the bronchial tree.
Questionnaires were distributed before and after the simulation experience. The presimulation questionnaire (Appendix) was used to identify prior surgical experience of the student as well as the student’s future career plans. Five-point Likert scales were utilized to assess the student’s attitudes toward surgery in general and specifically toward cardiothoracic surgery. Students were also asked to identify their future plans in the context of surgical rotations that they were likely to select for their third-year clerkship. The postsimulation questionnaire was used to measure the effectiveness of the simulators as well as the overall educational experience (Table 1). Attitudes toward surgery and cardiothoracic surgery were reassessed. Students were again asked which thirdyear surgical subspecialty clerkship they would be likely to select. The questionnaires were created specifically for this study. Their format and content approximates that of published studies in other surgical fields that utilize simulation courses [16, 17].
Thoracotomy Simulator
Terminology
The thoracotomy simulator consists of a porcine left lung and heart positioned within a life-sized artificial hemithorax. An opening comparable to a standard posteriolateral thoracotomy incision allows access into the hemithorax for lung manipulation. Pulmonary vessels are perfused with synthetic blood and mediastinal motion mimics that which
In this study, “cardiothoracic” is used to describe the surgical subspecialty as well as the training of the faculty who participated in the study. The terms cardiac and thoracic are used to identify the separate services that exist at the University of North Carolina. Students may choose to rotate on the cardiac rotation and/or the
Bronchoscopy Simulator
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The bronchoscopy simulator is a useful training and educational tool The thoracotomy simulator is a useful training and educational tool The thoracoscopy model is a useful training and educational tool The beating heart model is a useful and educational tool When participating on the simulators, I felt like I was engaged in a real operation I think more medical students would be interested in surgery if they were able to participate in simulator-based workshops Training on surgical simulators should be a mandatory part of the curriculum for medical students Training on surgical simulators should be a voluntary part of the curriculum for medical students Training on surgical simulators should only be offered to those medical students who are already interested in surgery I think surgical simulators would be helpful in training medical students After completing this workshop, I have a better understanding of what cardiothoracic surgery entails I learned new information and skills by participating in this simulator course By participating in this simulator session I am more prepared for third-year surgery clerkship I think that medical school offers enough exposure to each specialty to make an informed decision by fourth year about what residency to pursue Length of residency is an important factor in choosing a career
Strongly Agree (%)
Agree (%)
Neutral (%)
Disagree (%)
Strongly Disagree (%)
37 (84%)
7 (16%)
0
0
0
44 (95%)
2 (5%)
0
0
0
41 (91%)
3 (9%)
0
0
0
39 (88%)
5 (12%)
0
0
0
23 (52%)
20 (45%)
1 (2%)
0
0
30 (68%)
11 (25%)
3 (7%)
0
0
20 (45%)
16 (36%)
6 (14%)
2 (5%)
0
19 (43%)
10 (23%)
8 (18%)
5 (11%)
2 (5%)
5 (11%)
4 (9%)
4 (9%)
23 (52%)
8 (18%)
39 (89%)
5 (11%)
0
0
0
29 (66%)
14 (32%)
1 (2%)
0
0
39 (89%)
5 (11%)
0
0
0
21 (48%)
19 (43%)
4 (9%)
0
0
3 (7%)
5 (11%)
19 (43%)
14 (32%)
3 (7%)
2 (5%)
23 (52%)
15 (34%)
4 (9%)
0
thoracic (general thoracic, noncardiac) rotation during their third-year clerkship selectives.
Analysis Data were analyzed using the Statistical Package for the Social Sciences (version 16.0; SPSS Inc, Chicago, IL). Crosstabs comparisons of medical school year 1 and medical school year 2 was performed to justify merging data from those two groups, as the groups did not significantly differ on sex, experience, cardiothoracic experience, or simulation work. Nonparametric data were analyzed using Wilcoxon signed ranks test where appropriate.
Results Fifty-four (15%) of the first- and second-year class were active in the surgery interest group at the time of this study. Sixty percent of the students were female. This reflects the overall medical student population, in which 58% of the class is female. Forty-four (12%) first- and
second-year medical students participated in the cardiothoracic simulator training experience. All students were present at a brief 30-minute “introduction to the simulators” course and completed the subsequent simulator training experience in full. No participants were excluded from this study. All 44 students completed both the before and after simulation questionnaires. The majority of students in this study were female (26; 60%) and in their first year of medical school (34; 77%). All participants were members of the Surgery Interest Group at UNC-Chapel Hill. In the presimulation questionnaire, 80% (35) of the students either agreed or strongly agreed that they would like to pursue a career in surgery. From the same questionnaire, only 1 participant (2%) strongly agreed that he sought to pursue a career in cardiothoracic surgery. The majority of students (28; 64%) were “neutral” about a career in cardiothoracic surgery. Eighty-two percent of the students had previous experience in a surgical operating room. However, only 9% (4) of them had scrubbed into more than 5 cases. A significantly smaller percentage of
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Table 1. Postsimulation Questionnaire
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participants had experience in a cardiothoracic operating room (11; 25%), and only 1 had ever scrubbed into either a cardiac or a thoracic surgery case (Table 2). At the conclusion of the cardiothoracic simulation course, students completed a postsimulation questionnaire (Table 1). The participants universally indicated that the surgical simulators themselves were useful training and educational tools. Forty-three of the 44 students (97%) either agreed or strongly agreed that they felt as if they were engaged in a real operation while participating in the cardiothoracic simulation experience (Table 1). After completing diagnostic bronchoscopy, thoracotomy, thoracoscopy, and placement of cannulas for cardiopulmonary bypass, 66% (29) of participants strongly agreed that they had a better understanding of what cardiothoracic surgery entails. Thirty-six percent of the group (16) indicated a higher level of agreement with the statement that they would be interested in pursuing a career in cardiothoracic surgery. In contrast, there was only a 9% increase in the group’s overall attitude toward pursuing a career in surgery. Of the participants, 61% (27) either agreed or strongly agreed that they were interested in pursuing a career in cardiothoracic surgery after completion of the course versus 34% (15) in the initial survey. This was an overall increase of 27% (p ⫽ 0.001; Fig 1). The selection of thoracic surgery for a third-year clerkship rotation also increased after the students completed the simulator course. Initially, only 18% (8) of the students indicated that they would select thoracic surgery for a third-year clerkship rotation. After the course, this number rose to 39% of the students, a 21% increase (p ⫽ 0.253). A statistically significant increase was seen among Table 2. Demographics
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Fig 1. On both (A) the before simulation and (B) the after simulation questionnaires, students were asked to circle their level of agreement with the statement “I am interested in pursuing a career in cardiothoracic (CT) surgery.” There was a significant increase in number of students who agreed or strongly agreed with the statement after completion of the simulation course (62% versus 34%, p ⫽ 0.001).
the females who participated in the course where 12% (3) selected a thoracic rotation before the course versus 35% (9) after the course. This was a 23% overall increase in the selection of thoracic surgery for a third-year clerkship rotation among female participants (p ⬍ 0.05; Fig 2). Questions targeting the overall utility of the simulator course found that 86% (39) of the students strongly agreed that they learned new skills by participating in the course. Forty-eight percent (21) strongly agreed that they felt more prepared for third-year surgery clerkship after participating in the course, and 82% (36) agreed or strongly agreed that simulators should be a mandatory component of the medical school curriculum. The majority (41; 93%) thought that more medical students would be interested in surgery if they were able to participate in similar workshop, and 70% (31) disagreed or strongly disagreed with the statement that the simulator experience should be offered only to those already interested in surgery.
No. (%) Sex Male Female Medical school year MS 1 MS 2 Previous exposure to surgery None Observed but never scrubbed in Scrubbed into fewer than 5 cases Scrubbed into 5 or more cases Previous exposure to cardiothoracic surgery None Observed but never scrubbed in Scrubbed into fewer than 5 cases Scrubbed into 5 or more cases Previous exposure to surgical simulators Yes No Mentor in the department of surgery Yes No
18 (40%) 26 (60%) 34 (77%) 10 (23%) 8 (18%) 21 (48%) 11 (25%) 4 (9%) 33 (75%) 10 (23%) 1 (2%) 0 (0%) 1 (2%) 43 (98%) 16 (36%) 28 (64%)
Fig 2. Students were asked to circle which two selectives they would likely choose for their third-year surgery subspecialty rotations on both the before simulation (light bars) and after simulation (dark bars) questionnaires. Female medical students were significantly more likely to select thoracic surgery after completion of the simulator course (*p ⬍ 0.05). (ENT ⫽ ears, nose, and throat.)
Comment Duty hour restrictions and zero tolerance for medical error have changed the face of medical education. The adage “see one, do one, teach one” is no longer accepted as an appropriate educational strategy. To that end, simulated patients (living and inanimate) are increasingly utilized to teach diagnostic and therapeutic skills across disciplines [11, 12, 16, 18, 19]. Existing simulation courses in the field of cardiothoracic surgery such as the annual TSDA CT Boot Camp [13] and the Cardiothoracic Technology Symposium [14] are designed for instruction of the cardiothoracic fellow. Currently, little opportunity exists for the interested medical student to gain exposure to the field. This disparity will need to be addressed as more programs transition to 6-year integrated training paradigms. In this study, we took a novel approach as to how surgical simulators are utilized in medical education. It is well established that positive mentorship and hands-on involvement in the operating room are critical elements in determining career selection among surgeons [9, 20]. Simulation courses have been utilized in other surgical fields to provide medical students early hands-on exposure [17]. However, the utility of structured simulator courses in cardiothoracic career selection has not been investigated. In this study, students received mentored instruction by cardiothoracic attendings while performing diagnostic bronchoscopy, lobectomy, wedge resection, and placement of cannulas for cardiopulmonary bypass. The hands-on participation and mentored instruction in these tasks led the students to have a better understanding of what cardiothoracic surgery entails. This knowledge translated into increased interest in cardiothoracic surgery as a career for 36% of the group. Key components of the simulation course included the use of high-fidelity simulators as well as direct instruction by cardiothoracic faculty. Elucidating the influence of the faculty versus the use of simulators on the attitudes of the medical students who participated in this course is difficult. The study was designed to create a maximally realistic exposure to cardiothoracic surgery. This included the use of simulators that had realistic material and movement as well as expert faculty to provide relevant instruction. Anecdotal reports from the students indicated that the simulation experience was different and better exposure that they had previously encountered from strict didactic teaching. Similarly, we hypothesize that the simulators themselves would be much less useful, particularly for the junior medical student, without mentored instruction. In upcoming sessions, we plan to include targeted questions that address the role of the mentor in the simulation experience. Both male and female participants demonstrated a greater interest in thoracic surgery as a clerkship selective after completing the simulator course. However, this increase was statistically significant among the female participants (p ⬍ 0.05). Analysis of the data did not show any difference with regard to previous experience, or mentorship, of the females when compared with that of the males. However, initial interest in a thoracic surgery
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selective was significantly lower among the females (12%) than the males (28%) in this group. This study did not attempt to address any preexisting bias among the participants that may explain this disparity. It does raise an important point that female medical students appeared to be initially less interested in thoracic surgery but were particularly influenced by positive experiences in the simulated setting. Further investigation is warranted to explore the role of simulation courses as they pertain to the recruitment and training of female students. The simulation experience provided exposure to both thoracic as well as cardiac surgery. In analysis of the data, there was no significant change in interest in selection of cardiac surgery selective where there was an increased interest in the selection of thoracic surgery. We hypothesize two reasons for the discrepancy. First, there was a significant interest in cardiac surgery even before the simulation course with 45% of the students choosing the cardiac surgery selective. Detecting a difference in this already interested group may require a greater number of subjects. Second, there were three simulators dedicated to thoracic procedures and only one to cardiac. Students may have had disproportionately more exposure to thoracic surgery during the simulation course, thereby influencing their responses. The feasibility of integrating a cardiothoracic simulation course into the medical school curriculum is also an important topic to address. The majority of students who participated in the course indicated that the course should be available to all students independent of their interest in surgery. Furthermore, they suggested that it should be a mandatory part of the medical school education. Such an endeavor would require significant commitment from cardiothoracic surgeons who are already consumed with busy clinical practice. Indeed, finding adequate instructors has been the biggest hurdle for other similar simulation projects [21]. As the efficacy of the simulation course is proven, complete integration into medical school and residency curriculums will require dedicated faculty instructors to moderate the educational sessions. We recognize several weaknesses of this study. First, this is a single-institution study with a relatively small sample size. While initial trends in this group are statistically significant, larger scale studies will be necessary to demonstrate the true value of these simulation courses. Additionally, student’s attitudes were assessed immediately upon completion of simulation course. The finding of improved attitudes of the subjects toward cardiothoracic surgery may not accurately reflect long-term career choices. Longitudinal studies that follow students through their third-year clerkship selective and ultimate career path are under way. These studies will address the importance of timing and frequency of participation in simulator courses as they relate to career selection. In conclusion, the importance of early positive experiences within the field of cardiothoracic surgery must be underscored at a time when the discipline has a record low number of applicants. The use of high-fidelity surgical simulators allows medical students with no previous
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training to actively participate in relevant procedures within a protected environment. One-on-one instruction by qualified attendings provides the cornerstone of mentorship that is critical in shaping the career path of medical students. Ongoing investigation will determine the lasting effects of the simulation experience as these students progress through their careers. We appreciate the generous tissue donations from Prestage Farms of North Carolina that were used for creation of the thoracoscopic, thoracotomy, and open heart surgical simulators. We thank David Hollar for his assistance with statistical interpretation, and Dr Paul Ramphal, Dr Philip Pepple, and Melissa Readio, MS3, for their participation in the course. Funding for research was provided in part by an educational grant from the Thoracic Surgery Foundation for Research and Education. Surgical instruments utilized in the lobectomy and open heart portions of the simulator course were provided by Teleflex Medical (Research Triangle Park, North Carolina). Stapling devices and thoracoscopic instruments were provided through donations by Ethicon Endo-Surgery, Inc.
References 1. Salazar JD, Ermis P, Laudito A, Lee R, Wheatley GH, Paul S, Calhoon J. Cardiothoracic surgery resident education: update on resident recruitment and job placement. Ann Thorac Surg 2006;82:1160 –5. 2. NRMP match results statistics, thoracic surgery fellowship appointment year 2010. Available at: http://www.nrmp.org/ fellow/match_name/thoracic/stats.html. Accessed January 1, 2010. 3. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009; 137:1054 – 62. 4. Wilcox BR. The match and changing times. Available at: http://www.ctsnet.org/sections/newsandviews/specialreports/ article-5.html. Accessed January 1, 2010. 5. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488 –94. 6. Allen JG, Weiss ES, Patel ND, et al. Inspiring medical students to pursue surgical careers: outcomes from our cardiothoracic surgery research program. Ann Thorac Surg 2009;87:1816 –9.
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7. Berman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg 2008;207:793– 800. 8. Clifford KY, Escarce JJ, Baker L, Klein D, Guarino C. Predictors for medical students entering a general surgery residency: national survey results. Surgery 2004;136:567–72. 9. Cochran A, Melby S, Neumayer LA. An internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg 2005;189:742– 6. 10. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What influences medical students’ choice of surgical careers. Surgery 2000; 128:253– 6. 11. Fann JI, Caffarelli AD, Georgette G, et al. Improvement in coronary anastomosis with cardiac surgery simulation. J Thorac Cardiovasc Surg 2008;136:1486 –91. 12. Carter YM, Marshall MB. Open lobectomy simulator is an effective tool for teaching thoracic surgical skills. Ann Thorac Surg 2009;87:1546 –51. 13. TSDA CT Boot Camp. Available at: http://www.tsda.org/ sections/meetings/Boot%20Camp%202008/index.html. Accessed January 1, 2010. 14. Cardiothoracic Technology Symposium. Available at: http:// www.ctsymposium.org/node/597.html. Accessed January 1, 2010. 15. Ramphal PS, Coore DN, Craven MP, et al. A high fidelity tissue-based cardiac surgical simulator. Eur J Cardiothorac Surg 2005;27:910 – 6. 16. Passman MA, Fleser PS, Datillo JB, Guzman RJ, Naslund TC. Should simulator-based endovascular training be integrated into general surgery residency programs. Am J Surg 2007; 194:212–9. 17. Lee J, Qiu M, Teshome M, Raghavan S, Tedesco M, Dalman R. The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery. J Surg Educ 2009;66:367–73. 18. Xeroulis G, Dubrowski A, Leslie K. Simulation in laparoscopic surgery: a concurrent validity study for FLS. Surg Endosc 2009;23:161–5. 19. Iwasaki A, Okabayashi K, Shirakusa T. A model to assist training in thoracoscopic surgery. Interact Cardiovasc Thorac Surg 2003;2:697–701. 20. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125– 8. 21. Feins RH. Expert commentary: cardiothoracic surgical simulation. J Cardiovasc Surg 2008;135:485– 6.
Appendix Presimulation Questionnaire Medical school year ______
Gender _____
Please circle the appropriate answer. 1. My previous experience in an operating room is None Observed but didn’t scrub in
Scrubbed in on ⬍5 cases
Scrubbed in on ⬎5 cases
2. My previous experience with cardiothoracic surgery is None Observed but didn’t scrub in
Scrubbed in on ⬍5 cases
Scrubbed in on ⬎5 cases
3. I have worked with surgery simulators in the past Yes No Continued
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4. I am interested in pursuing a career in surgery Strongly Agree Agree Strongly Disagree
Neutral
Disagree
5. I am interested in pursuing a career in cardiothoracic surgery Strongly Agree Agree Strongly Disagree
Neutral
Disagree
6. I think surgical simulators would be helpful in training medical students Strongly Agree Agree Strongly Disagree
Neutral
Disagree
7. I have a mentor in the department of surgery Yes If yes, in which division __________________________________
No
Select 2 ENT Burn Cardiac
Ophthalmology Orthopedics Plastics
Thoracic Transplant Urology
Vascular
DISCUSSION DR MICHAEL F. REED (Cincinnati, OH): Dr Murray, Dr Wood, members and guests. It is my honor to discuss this paper. I have no relevant financial interest to disclose. I congratulate the Society leadership for including a paper focusing on education in this general session. As many have correctly acknowledged, the future of our profession and the ongoing advancement of care for patients with cardiothoracic diseases requires improved recruitment of competent and dedicated individuals committed to our field. It is admirable that the group from the University of North Carolina has applied hypothesis-driven methodology to the study of educational strategies, akin to evidence-based approaches to clinical and scientific questions. A recent study demonstrated that the duration of general surgery resident exposure to cardiothoracic surgery on clinical rotations directly correlated with their interest in the field, and multiple reports have indicated that surgical career choices are most influenced by participation in procedures and positive role models. The UNC group has suggested that earlier exposure to cardiothoracic surgery through successful implementation of these two goals, namely, hands-on experience and mentoring, might enhance interest in our specialty. They hypothesize that mentored instruction using cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery. In this single institution study, first- and second-year medical students were recruited from a surgical interest group. This is a clear selection bias, but it is the very group that we are likely to attract into our specialty. They received mentored instruction on high-fidelity cardiothoracic simulators. Before the course, one third were interested in pursuing a career in cardiothoracic surgery, while afterward almost two thirds were. This heightened interest in cardiothoracic surgery carried through to their selection of third-year subspecialty rotations. As the authors note in their well-written manuscript, longitudinal studies are essential to demonstrate whether these interventions will yield sustained results regarding ultimate career choices. This will
require a much larger multi-institutional cohort. I have three questions. First, Dr Murray in his presidential address yesterday noted that “we must specifically attract a talented applicant pool of women,” and as the husband of a female vascular surgeon, I certainly concur. In the editorial mentioned earlier, only 3% of general surgery residents were committed to cardiothoracic surgery, but 14% were interested. There is a clear opportunity for recruitment. In this paper, the increased interest in rotating on thoracic surgery after the mentored course was most evident among females. Can you comment on why a mentored simulator experience was particularly effective for women? Second, this study evaluated the effect of a mentored simulator program. Can you separate the impact of mentorship versus simulation? And finally, third, does the nature of the simulator matter or is any thoracic surgical simulation modality effective? I would like to thank the Society for the opportunity to discuss this paper. DR TESCHE: Thank you very much for your comments and questions. The first question addressed the findings among the female participants in this study. In review of the data, there was no difference between the males or females in either previous exposure or mentorship within the field of cardiothoracic surgery. However, there were significantly fewer female participants who expressed interest in a thoracic rotation before the simulation experience. The study did not address any preexisting bias that may exist in the group, but one may speculate that lack of role models may contribute to this finding. Both the males and females were more interested in a rotation in thoracic surgery after the simulation experience, but this was statistically significant among the female participants. Further investigation is necessary to delineate exactly what is it about a surgical simulation experience that appeals to women. This type of investigation would be important and timely, as women now account for 50% of the graduating medical class.
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Appendix. Continued
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The second question asked if our findings were because of students experience with the simulators themselves or if it was due to faculty mentorship. I favor the latter. These simulators would not work without dedicated support from the faculty members and the expertise and clinical knowledge that they provide. The simulators provide a forum for the students and faculty to interact in a relevant setting. Finally, the third question addressed the nature of the simulators. We use high-fidelity cardiothoracic surgery simulators in our center. That is what we have designed and have experience with. We believe that if we can recreate the operating room, then participants will have a realistic experience that is easier to
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translate into practice. We don’t have any studies that compare our model to others. For medical students, I think that hands-on experience on any type of relevant model and positive mentorship from cardiothoracic faculty are the first steps to recruitment. DR DOUGLAS E. WOOD (Seattle, WA): I would certainly like to acknowledge a terrific paper, and it is great to see Dr Tesche up here as a general surgery resident presenting to our group and the leadership of the UNC group in developing these educational models of simulation. It is truly a great advance educationally for our specialty. Thank you.
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Background. Applications to cardiothoracic training programs have declined dramatically. Increased effort in recruiting trainees is paramount. In this study, we test our hypothesis that mentored instruction on cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery. Methods. First- and second-year medical students were recruited from a “surgery interest group” to receive mentored instruction on high-fidelity cardiothoracic simulators. Before and after simulation assessment tools were used to assess attitudes toward simulation, general surgery, and cardiothoracic surgery. Results. Forty-four medical students participated in the study. Although 80% of the students were interested in pursuing a career in surgery before the course, the majority (64%) indicated they were “neutral” about pursuing a career in cardiothoracic surgery. After participating in the course, 61% of the students agreed or strongly agreed that they were interested in pursuing a career in
cardiothoracic surgery (p ⴝ 0.001). When asked to select a surgical subspecialty for their third-year clerkship rotation, 18% of the students selected thoracic surgery before participating in the simulator course versus 39% after completing the course. This increase was most evident among the female participants, of whom only 3 (12%) selected a thoracic rotation before the simulator course versus 9 (35%) after completion of the course (p < 0.05). Conclusions. High-fidelity surgical simulators are an effective way to introduce medical students to cardiothoracic surgery. Participation in moderated simulator sessions improves attitudes toward cardiothoracic surgery as a career choice and correlates with a greater interest in selecting thoracic surgery as a third-year clerkship rotation. The role of surgical simulation as a recruitment tool should be further delineated.
I
potential recruits to gain exposure to the field of cardiothoracic surgery. First, duty hour restrictions have resulted in decreased time spent on subspecialty service rotations during general surgery training [5]. General surgery residents now have limited access to mentors within the field of cardiothoracic surgery. Second, the technically challenging nature of cardiothoracic procedures and tight margin for error make it difficult for junior residents to gain hands-on exposure in the operating room. Limited exposure to cardiothoracic surgery hinders recruitment as residents are asked to make career choices about field in which they have insufficient experience. As more integrated training tracts become available, the lack of exposure to cardiothoracic surgery will affect not only the general surgery applicant but medical students as well. To attract more trainees into the field of cardiothoracic surgery, new methods of recruitment are being explored. In this study, we describe the use of a surgical simulation course as a means to provide junior medical students exposure to cardiothoracic surgery. Surgical simulation is currently utilized to augment the education of residents in many different fields of surgery. Through structured courses, residents can be taught new procedures and surgical competency can be assessed [11, 12]. At the
n the past decade, the field of cardiothoracic surgery has witnessed a progressive decline in the number of applicants [1, 2]. Only 68% of accredited cardiothoracic programs matched residents in 2009 [3]. At the same time, more than 50% of those in the cardiothoracic workforce are over the age of 55 and expected to retire within the next 10 years [4, 5]. This disparity is projected to result in an 18% overall decrease in practicing cardiothoracic surgeons by 2010 [5]. As the “baby boom” population continues to age, the demand for qualified cardiothoracic surgeons is expected to increase [5]. To ensure sustainability of the profession and appropriate supply of qualified surgeons, increased efforts in the recruitment of trainees in cardiothoracic surgery is paramount. Studies demonstrate that, among junior residents, surgical career selection is most influenced by hands-on participation and positive mentorship within a field [3, 6 –10]. Several factors make it particularly difficult for
Accepted for publication June 29, 2010. Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010. Address correspondence to Dr Tesche, Department of Surgery, CB#7050, 4001 Burnett-Womack Bldg, Chapel Hill, NC 27599; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
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Simulation Experience Enhances Medical Students’ Interest in Cardiothoracic Surgery
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University of North Carolina at Chapel Hill, we have experience in the design of high-fidelity cardiac and pulmonary simulators that have been utilized in the instruction of cardiothoracic residents at national training courses [13, 14]. These simulators allow participants to perform complex cardiothoracic procedures in a realistic, yet protected, environment. Thus far, the simulators have been utilized for senior level instruction. However, we propose that the application of these simulators be extended to include instruction of medical students as well. In this study, we test our hypothesis that mentored instruction by cardiothoracic attendings on high-fidelity cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery.
Material and Methods The Surgery Interest Group at the University of North Carolina at Chapel Hill is an organization open to all first- and second-year medical students who express interest in surgery. Approximately 15% of the 320 firstand second-year students choose to participate each year. These members were offered the opportunity to participate in the cardiothoracic simulation course. During this half-day course, students received mentored instruction by cardiothoracic attendings on four highfidelity simulators: virtual bronchoscopy, thoracotomy, thoracoscopy, and beating heart models. (The thoracotomy and thoracoscopy simulators were designed and created by medical students and residents at UNC– Chapel Hill.) Students were paired in groups of two and given 30 minutes to perform mentored procedures on each model. Participants in the course wore surgical attire, and all models were properly draped to replicate the operating room experience. Before the course, the students were given a brief introduction to relevant anatomy as well as instruction on basic instrument handling. This study was reviewed and approved by the University of North Carolina Medical Institutional Review Board.
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is encountered during single lung ventilation. For this station, the participants were oriented to the anatomy of the lung and performed portions of a lobectomy including vessel isolation and ligation and removal of various anatomic segments of the lung. The students were also introduced to surgical stapling techniques.
Thoracoscopic Simulator The thoracoscopic simulator utilizes porcine right lungs injected with silicone in random positions on the lung surface to represent tumors. The lungs are positioned within a life-sized artificial hemithorax. Two openings in the hemithorax accommodate 12-mm ports for the thoracoscope and thoracoscopic instruments. A third opening in the fourth interspace of the midaxillary line is used for additional thoracoscopic instrumentation as well as tissue removal. In this station, participants were introduced to thoracoscopic surgery and techniques. The students were given the tasks of identifying pulmonary lesions and performing thoracoscopic wedge resection of these lesions.
Cardiac Simulator The cardiac simulator is a high-fidelity instrument that utilizes porcine hearts [15]. The hearts have been prepared so that, when connected to a computerized pneumatic pump, they are able to simulate cardiac movement. The coronary vessels and aortic root are fully perfused with synthetic blood. For this station students were oriented to cardiac anatomy, instructed on the fundamentals of cardiopulmonary bypass and placed aortic and venous cannulas.
Assessment Tools
The bronchoscopy simulator (AccuTouch; Immersion Medical, San Jose, CA) uses computer simulation to provide virtual images of endobronchial anatomy while the student manipulates a bronchoscope. The software on this model enables trainees to rehearse different clinical scenarios. For this task, the medical students completed a diagnostic bronchoscopy. This station emphasized techniques of bronchoscope manipulation, anatomy of the airway, and identification of lesions within the bronchial tree.
Questionnaires were distributed before and after the simulation experience. The presimulation questionnaire (Appendix) was used to identify prior surgical experience of the student as well as the student’s future career plans. Five-point Likert scales were utilized to assess the student’s attitudes toward surgery in general and specifically toward cardiothoracic surgery. Students were also asked to identify their future plans in the context of surgical rotations that they were likely to select for their third-year clerkship. The postsimulation questionnaire was used to measure the effectiveness of the simulators as well as the overall educational experience (Table 1). Attitudes toward surgery and cardiothoracic surgery were reassessed. Students were again asked which thirdyear surgical subspecialty clerkship they would be likely to select. The questionnaires were created specifically for this study. Their format and content approximates that of published studies in other surgical fields that utilize simulation courses [16, 17].
Thoracotomy Simulator
Terminology
The thoracotomy simulator consists of a porcine left lung and heart positioned within a life-sized artificial hemithorax. An opening comparable to a standard posteriolateral thoracotomy incision allows access into the hemithorax for lung manipulation. Pulmonary vessels are perfused with synthetic blood and mediastinal motion mimics that which
In this study, “cardiothoracic” is used to describe the surgical subspecialty as well as the training of the faculty who participated in the study. The terms cardiac and thoracic are used to identify the separate services that exist at the University of North Carolina. Students may choose to rotate on the cardiac rotation and/or the
Bronchoscopy Simulator
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The bronchoscopy simulator is a useful training and educational tool The thoracotomy simulator is a useful training and educational tool The thoracoscopy model is a useful training and educational tool The beating heart model is a useful and educational tool When participating on the simulators, I felt like I was engaged in a real operation I think more medical students would be interested in surgery if they were able to participate in simulator-based workshops Training on surgical simulators should be a mandatory part of the curriculum for medical students Training on surgical simulators should be a voluntary part of the curriculum for medical students Training on surgical simulators should only be offered to those medical students who are already interested in surgery I think surgical simulators would be helpful in training medical students After completing this workshop, I have a better understanding of what cardiothoracic surgery entails I learned new information and skills by participating in this simulator course By participating in this simulator session I am more prepared for third-year surgery clerkship I think that medical school offers enough exposure to each specialty to make an informed decision by fourth year about what residency to pursue Length of residency is an important factor in choosing a career
Strongly Agree (%)
Agree (%)
Neutral (%)
Disagree (%)
Strongly Disagree (%)
37 (84%)
7 (16%)
0
0
0
44 (95%)
2 (5%)
0
0
0
41 (91%)
3 (9%)
0
0
0
39 (88%)
5 (12%)
0
0
0
23 (52%)
20 (45%)
1 (2%)
0
0
30 (68%)
11 (25%)
3 (7%)
0
0
20 (45%)
16 (36%)
6 (14%)
2 (5%)
0
19 (43%)
10 (23%)
8 (18%)
5 (11%)
2 (5%)
5 (11%)
4 (9%)
4 (9%)
23 (52%)
8 (18%)
39 (89%)
5 (11%)
0
0
0
29 (66%)
14 (32%)
1 (2%)
0
0
39 (89%)
5 (11%)
0
0
0
21 (48%)
19 (43%)
4 (9%)
0
0
3 (7%)
5 (11%)
19 (43%)
14 (32%)
3 (7%)
2 (5%)
23 (52%)
15 (34%)
4 (9%)
0
thoracic (general thoracic, noncardiac) rotation during their third-year clerkship selectives.
Analysis Data were analyzed using the Statistical Package for the Social Sciences (version 16.0; SPSS Inc, Chicago, IL). Crosstabs comparisons of medical school year 1 and medical school year 2 was performed to justify merging data from those two groups, as the groups did not significantly differ on sex, experience, cardiothoracic experience, or simulation work. Nonparametric data were analyzed using Wilcoxon signed ranks test where appropriate.
Results Fifty-four (15%) of the first- and second-year class were active in the surgery interest group at the time of this study. Sixty percent of the students were female. This reflects the overall medical student population, in which 58% of the class is female. Forty-four (12%) first- and
second-year medical students participated in the cardiothoracic simulator training experience. All students were present at a brief 30-minute “introduction to the simulators” course and completed the subsequent simulator training experience in full. No participants were excluded from this study. All 44 students completed both the before and after simulation questionnaires. The majority of students in this study were female (26; 60%) and in their first year of medical school (34; 77%). All participants were members of the Surgery Interest Group at UNC-Chapel Hill. In the presimulation questionnaire, 80% (35) of the students either agreed or strongly agreed that they would like to pursue a career in surgery. From the same questionnaire, only 1 participant (2%) strongly agreed that he sought to pursue a career in cardiothoracic surgery. The majority of students (28; 64%) were “neutral” about a career in cardiothoracic surgery. Eighty-two percent of the students had previous experience in a surgical operating room. However, only 9% (4) of them had scrubbed into more than 5 cases. A significantly smaller percentage of
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Table 1. Postsimulation Questionnaire
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participants had experience in a cardiothoracic operating room (11; 25%), and only 1 had ever scrubbed into either a cardiac or a thoracic surgery case (Table 2). At the conclusion of the cardiothoracic simulation course, students completed a postsimulation questionnaire (Table 1). The participants universally indicated that the surgical simulators themselves were useful training and educational tools. Forty-three of the 44 students (97%) either agreed or strongly agreed that they felt as if they were engaged in a real operation while participating in the cardiothoracic simulation experience (Table 1). After completing diagnostic bronchoscopy, thoracotomy, thoracoscopy, and placement of cannulas for cardiopulmonary bypass, 66% (29) of participants strongly agreed that they had a better understanding of what cardiothoracic surgery entails. Thirty-six percent of the group (16) indicated a higher level of agreement with the statement that they would be interested in pursuing a career in cardiothoracic surgery. In contrast, there was only a 9% increase in the group’s overall attitude toward pursuing a career in surgery. Of the participants, 61% (27) either agreed or strongly agreed that they were interested in pursuing a career in cardiothoracic surgery after completion of the course versus 34% (15) in the initial survey. This was an overall increase of 27% (p ⫽ 0.001; Fig 1). The selection of thoracic surgery for a third-year clerkship rotation also increased after the students completed the simulator course. Initially, only 18% (8) of the students indicated that they would select thoracic surgery for a third-year clerkship rotation. After the course, this number rose to 39% of the students, a 21% increase (p ⫽ 0.253). A statistically significant increase was seen among Table 2. Demographics
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Fig 1. On both (A) the before simulation and (B) the after simulation questionnaires, students were asked to circle their level of agreement with the statement “I am interested in pursuing a career in cardiothoracic (CT) surgery.” There was a significant increase in number of students who agreed or strongly agreed with the statement after completion of the simulation course (62% versus 34%, p ⫽ 0.001).
the females who participated in the course where 12% (3) selected a thoracic rotation before the course versus 35% (9) after the course. This was a 23% overall increase in the selection of thoracic surgery for a third-year clerkship rotation among female participants (p ⬍ 0.05; Fig 2). Questions targeting the overall utility of the simulator course found that 86% (39) of the students strongly agreed that they learned new skills by participating in the course. Forty-eight percent (21) strongly agreed that they felt more prepared for third-year surgery clerkship after participating in the course, and 82% (36) agreed or strongly agreed that simulators should be a mandatory component of the medical school curriculum. The majority (41; 93%) thought that more medical students would be interested in surgery if they were able to participate in similar workshop, and 70% (31) disagreed or strongly disagreed with the statement that the simulator experience should be offered only to those already interested in surgery.
No. (%) Sex Male Female Medical school year MS 1 MS 2 Previous exposure to surgery None Observed but never scrubbed in Scrubbed into fewer than 5 cases Scrubbed into 5 or more cases Previous exposure to cardiothoracic surgery None Observed but never scrubbed in Scrubbed into fewer than 5 cases Scrubbed into 5 or more cases Previous exposure to surgical simulators Yes No Mentor in the department of surgery Yes No
18 (40%) 26 (60%) 34 (77%) 10 (23%) 8 (18%) 21 (48%) 11 (25%) 4 (9%) 33 (75%) 10 (23%) 1 (2%) 0 (0%) 1 (2%) 43 (98%) 16 (36%) 28 (64%)
Fig 2. Students were asked to circle which two selectives they would likely choose for their third-year surgery subspecialty rotations on both the before simulation (light bars) and after simulation (dark bars) questionnaires. Female medical students were significantly more likely to select thoracic surgery after completion of the simulator course (*p ⬍ 0.05). (ENT ⫽ ears, nose, and throat.)
Comment Duty hour restrictions and zero tolerance for medical error have changed the face of medical education. The adage “see one, do one, teach one” is no longer accepted as an appropriate educational strategy. To that end, simulated patients (living and inanimate) are increasingly utilized to teach diagnostic and therapeutic skills across disciplines [11, 12, 16, 18, 19]. Existing simulation courses in the field of cardiothoracic surgery such as the annual TSDA CT Boot Camp [13] and the Cardiothoracic Technology Symposium [14] are designed for instruction of the cardiothoracic fellow. Currently, little opportunity exists for the interested medical student to gain exposure to the field. This disparity will need to be addressed as more programs transition to 6-year integrated training paradigms. In this study, we took a novel approach as to how surgical simulators are utilized in medical education. It is well established that positive mentorship and hands-on involvement in the operating room are critical elements in determining career selection among surgeons [9, 20]. Simulation courses have been utilized in other surgical fields to provide medical students early hands-on exposure [17]. However, the utility of structured simulator courses in cardiothoracic career selection has not been investigated. In this study, students received mentored instruction by cardiothoracic attendings while performing diagnostic bronchoscopy, lobectomy, wedge resection, and placement of cannulas for cardiopulmonary bypass. The hands-on participation and mentored instruction in these tasks led the students to have a better understanding of what cardiothoracic surgery entails. This knowledge translated into increased interest in cardiothoracic surgery as a career for 36% of the group. Key components of the simulation course included the use of high-fidelity simulators as well as direct instruction by cardiothoracic faculty. Elucidating the influence of the faculty versus the use of simulators on the attitudes of the medical students who participated in this course is difficult. The study was designed to create a maximally realistic exposure to cardiothoracic surgery. This included the use of simulators that had realistic material and movement as well as expert faculty to provide relevant instruction. Anecdotal reports from the students indicated that the simulation experience was different and better exposure that they had previously encountered from strict didactic teaching. Similarly, we hypothesize that the simulators themselves would be much less useful, particularly for the junior medical student, without mentored instruction. In upcoming sessions, we plan to include targeted questions that address the role of the mentor in the simulation experience. Both male and female participants demonstrated a greater interest in thoracic surgery as a clerkship selective after completing the simulator course. However, this increase was statistically significant among the female participants (p ⬍ 0.05). Analysis of the data did not show any difference with regard to previous experience, or mentorship, of the females when compared with that of the males. However, initial interest in a thoracic surgery
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selective was significantly lower among the females (12%) than the males (28%) in this group. This study did not attempt to address any preexisting bias among the participants that may explain this disparity. It does raise an important point that female medical students appeared to be initially less interested in thoracic surgery but were particularly influenced by positive experiences in the simulated setting. Further investigation is warranted to explore the role of simulation courses as they pertain to the recruitment and training of female students. The simulation experience provided exposure to both thoracic as well as cardiac surgery. In analysis of the data, there was no significant change in interest in selection of cardiac surgery selective where there was an increased interest in the selection of thoracic surgery. We hypothesize two reasons for the discrepancy. First, there was a significant interest in cardiac surgery even before the simulation course with 45% of the students choosing the cardiac surgery selective. Detecting a difference in this already interested group may require a greater number of subjects. Second, there were three simulators dedicated to thoracic procedures and only one to cardiac. Students may have had disproportionately more exposure to thoracic surgery during the simulation course, thereby influencing their responses. The feasibility of integrating a cardiothoracic simulation course into the medical school curriculum is also an important topic to address. The majority of students who participated in the course indicated that the course should be available to all students independent of their interest in surgery. Furthermore, they suggested that it should be a mandatory part of the medical school education. Such an endeavor would require significant commitment from cardiothoracic surgeons who are already consumed with busy clinical practice. Indeed, finding adequate instructors has been the biggest hurdle for other similar simulation projects [21]. As the efficacy of the simulation course is proven, complete integration into medical school and residency curriculums will require dedicated faculty instructors to moderate the educational sessions. We recognize several weaknesses of this study. First, this is a single-institution study with a relatively small sample size. While initial trends in this group are statistically significant, larger scale studies will be necessary to demonstrate the true value of these simulation courses. Additionally, student’s attitudes were assessed immediately upon completion of simulation course. The finding of improved attitudes of the subjects toward cardiothoracic surgery may not accurately reflect long-term career choices. Longitudinal studies that follow students through their third-year clerkship selective and ultimate career path are under way. These studies will address the importance of timing and frequency of participation in simulator courses as they relate to career selection. In conclusion, the importance of early positive experiences within the field of cardiothoracic surgery must be underscored at a time when the discipline has a record low number of applicants. The use of high-fidelity surgical simulators allows medical students with no previous
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training to actively participate in relevant procedures within a protected environment. One-on-one instruction by qualified attendings provides the cornerstone of mentorship that is critical in shaping the career path of medical students. Ongoing investigation will determine the lasting effects of the simulation experience as these students progress through their careers. We appreciate the generous tissue donations from Prestage Farms of North Carolina that were used for creation of the thoracoscopic, thoracotomy, and open heart surgical simulators. We thank David Hollar for his assistance with statistical interpretation, and Dr Paul Ramphal, Dr Philip Pepple, and Melissa Readio, MS3, for their participation in the course. Funding for research was provided in part by an educational grant from the Thoracic Surgery Foundation for Research and Education. Surgical instruments utilized in the lobectomy and open heart portions of the simulator course were provided by Teleflex Medical (Research Triangle Park, North Carolina). Stapling devices and thoracoscopic instruments were provided through donations by Ethicon Endo-Surgery, Inc.
References 1. Salazar JD, Ermis P, Laudito A, Lee R, Wheatley GH, Paul S, Calhoon J. Cardiothoracic surgery resident education: update on resident recruitment and job placement. Ann Thorac Surg 2006;82:1160 –5. 2. NRMP match results statistics, thoracic surgery fellowship appointment year 2010. Available at: http://www.nrmp.org/ fellow/match_name/thoracic/stats.html. Accessed January 1, 2010. 3. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009; 137:1054 – 62. 4. Wilcox BR. The match and changing times. Available at: http://www.ctsnet.org/sections/newsandviews/specialreports/ article-5.html. Accessed January 1, 2010. 5. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488 –94. 6. Allen JG, Weiss ES, Patel ND, et al. Inspiring medical students to pursue surgical careers: outcomes from our cardiothoracic surgery research program. Ann Thorac Surg 2009;87:1816 –9.
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7. Berman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg 2008;207:793– 800. 8. Clifford KY, Escarce JJ, Baker L, Klein D, Guarino C. Predictors for medical students entering a general surgery residency: national survey results. Surgery 2004;136:567–72. 9. Cochran A, Melby S, Neumayer LA. An internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg 2005;189:742– 6. 10. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What influences medical students’ choice of surgical careers. Surgery 2000; 128:253– 6. 11. Fann JI, Caffarelli AD, Georgette G, et al. Improvement in coronary anastomosis with cardiac surgery simulation. J Thorac Cardiovasc Surg 2008;136:1486 –91. 12. Carter YM, Marshall MB. Open lobectomy simulator is an effective tool for teaching thoracic surgical skills. Ann Thorac Surg 2009;87:1546 –51. 13. TSDA CT Boot Camp. Available at: http://www.tsda.org/ sections/meetings/Boot%20Camp%202008/index.html. Accessed January 1, 2010. 14. Cardiothoracic Technology Symposium. Available at: http:// www.ctsymposium.org/node/597.html. Accessed January 1, 2010. 15. Ramphal PS, Coore DN, Craven MP, et al. A high fidelity tissue-based cardiac surgical simulator. Eur J Cardiothorac Surg 2005;27:910 – 6. 16. Passman MA, Fleser PS, Datillo JB, Guzman RJ, Naslund TC. Should simulator-based endovascular training be integrated into general surgery residency programs. Am J Surg 2007; 194:212–9. 17. Lee J, Qiu M, Teshome M, Raghavan S, Tedesco M, Dalman R. The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery. J Surg Educ 2009;66:367–73. 18. Xeroulis G, Dubrowski A, Leslie K. Simulation in laparoscopic surgery: a concurrent validity study for FLS. Surg Endosc 2009;23:161–5. 19. Iwasaki A, Okabayashi K, Shirakusa T. A model to assist training in thoracoscopic surgery. Interact Cardiovasc Thorac Surg 2003;2:697–701. 20. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125– 8. 21. Feins RH. Expert commentary: cardiothoracic surgical simulation. J Cardiovasc Surg 2008;135:485– 6.
Appendix Presimulation Questionnaire Medical school year ______
Gender _____
Please circle the appropriate answer. 1. My previous experience in an operating room is None Observed but didn’t scrub in
Scrubbed in on ⬍5 cases
Scrubbed in on ⬎5 cases
2. My previous experience with cardiothoracic surgery is None Observed but didn’t scrub in
Scrubbed in on ⬍5 cases
Scrubbed in on ⬎5 cases
3. I have worked with surgery simulators in the past Yes No Continued
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4. I am interested in pursuing a career in surgery Strongly Agree Agree Strongly Disagree
Neutral
Disagree
5. I am interested in pursuing a career in cardiothoracic surgery Strongly Agree Agree Strongly Disagree
Neutral
Disagree
6. I think surgical simulators would be helpful in training medical students Strongly Agree Agree Strongly Disagree
Neutral
Disagree
7. I have a mentor in the department of surgery Yes If yes, in which division __________________________________
No
Select 2 ENT Burn Cardiac
Ophthalmology Orthopedics Plastics
Thoracic Transplant Urology
Vascular
DISCUSSION DR MICHAEL F. REED (Cincinnati, OH): Dr Murray, Dr Wood, members and guests. It is my honor to discuss this paper. I have no relevant financial interest to disclose. I congratulate the Society leadership for including a paper focusing on education in this general session. As many have correctly acknowledged, the future of our profession and the ongoing advancement of care for patients with cardiothoracic diseases requires improved recruitment of competent and dedicated individuals committed to our field. It is admirable that the group from the University of North Carolina has applied hypothesis-driven methodology to the study of educational strategies, akin to evidence-based approaches to clinical and scientific questions. A recent study demonstrated that the duration of general surgery resident exposure to cardiothoracic surgery on clinical rotations directly correlated with their interest in the field, and multiple reports have indicated that surgical career choices are most influenced by participation in procedures and positive role models. The UNC group has suggested that earlier exposure to cardiothoracic surgery through successful implementation of these two goals, namely, hands-on experience and mentoring, might enhance interest in our specialty. They hypothesize that mentored instruction using cardiothoracic simulators will enhance the interest of junior medical students in cardiothoracic surgery. In this single institution study, first- and second-year medical students were recruited from a surgical interest group. This is a clear selection bias, but it is the very group that we are likely to attract into our specialty. They received mentored instruction on high-fidelity cardiothoracic simulators. Before the course, one third were interested in pursuing a career in cardiothoracic surgery, while afterward almost two thirds were. This heightened interest in cardiothoracic surgery carried through to their selection of third-year subspecialty rotations. As the authors note in their well-written manuscript, longitudinal studies are essential to demonstrate whether these interventions will yield sustained results regarding ultimate career choices. This will
require a much larger multi-institutional cohort. I have three questions. First, Dr Murray in his presidential address yesterday noted that “we must specifically attract a talented applicant pool of women,” and as the husband of a female vascular surgeon, I certainly concur. In the editorial mentioned earlier, only 3% of general surgery residents were committed to cardiothoracic surgery, but 14% were interested. There is a clear opportunity for recruitment. In this paper, the increased interest in rotating on thoracic surgery after the mentored course was most evident among females. Can you comment on why a mentored simulator experience was particularly effective for women? Second, this study evaluated the effect of a mentored simulator program. Can you separate the impact of mentorship versus simulation? And finally, third, does the nature of the simulator matter or is any thoracic surgical simulation modality effective? I would like to thank the Society for the opportunity to discuss this paper. DR TESCHE: Thank you very much for your comments and questions. The first question addressed the findings among the female participants in this study. In review of the data, there was no difference between the males or females in either previous exposure or mentorship within the field of cardiothoracic surgery. However, there were significantly fewer female participants who expressed interest in a thoracic rotation before the simulation experience. The study did not address any preexisting bias that may exist in the group, but one may speculate that lack of role models may contribute to this finding. Both the males and females were more interested in a rotation in thoracic surgery after the simulation experience, but this was statistically significant among the female participants. Further investigation is necessary to delineate exactly what is it about a surgical simulation experience that appeals to women. This type of investigation would be important and timely, as women now account for 50% of the graduating medical class.
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TESCHE ET AL SIMULATION ENHANCES INTEREST IN CT SURGERY
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The second question asked if our findings were because of students experience with the simulators themselves or if it was due to faculty mentorship. I favor the latter. These simulators would not work without dedicated support from the faculty members and the expertise and clinical knowledge that they provide. The simulators provide a forum for the students and faculty to interact in a relevant setting. Finally, the third question addressed the nature of the simulators. We use high-fidelity cardiothoracic surgery simulators in our center. That is what we have designed and have experience with. We believe that if we can recreate the operating room, then participants will have a realistic experience that is easier to
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translate into practice. We don’t have any studies that compare our model to others. For medical students, I think that hands-on experience on any type of relevant model and positive mentorship from cardiothoracic faculty are the first steps to recruitment. DR DOUGLAS E. WOOD (Seattle, WA): I would certainly like to acknowledge a terrific paper, and it is great to see Dr Tesche up here as a general surgery resident presenting to our group and the leadership of the UNC group in developing these educational models of simulation. It is truly a great advance educationally for our specialty. Thank you.
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